HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CARLTON LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record Ny"V SO-
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
local Board of Health to determine the form they use. The System Pumping.Record must be submitte
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - -
HOUSE: front ack side rear, le ri
A. Facility Information BUILDING: ont back side rear eft ril
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, I-g
use only the lab I
key to move your Ad ress ` WW
cursor.do not (J'�'ty_` (►/�`
use the return City/Town Slate Zip Code
key.
2. S stw Owner:
SGli, ,
Name
inwn
Address(if different from location)
Cily/Town . Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oa�'� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease TraK
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [] Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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System Pumping Record -Page '
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